INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on November 26 through 29, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Kirkbride Center was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection:
|
Plan of Correction
|
704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
|
Observations
Based on a review of the Staffing Requirements Facility Summary Report, and a review of personnel records, the facility failed to ensure that staff persons and volunteers received a minimum of 6 hours of HIV/AIDS training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
The findings include:
Personnel records and the Staffing Requirements Facility Summary Report were reviewed on November 26, 2012.
The facility failed to ensure that employee # 14 completed the required HIV/AIDS training.
Employee # 14 was hired 6/20/10.
Employee # 14 is a support staff member, van driver.
HIV/AIDS training was to be completed within the first 2 years of employment, by 6/20/12
At the time of review on November 26, 2012, employee # 14 had not received the HIV/AIDS training.
The Project Director confirmed the findings.
This is a repeat citation. The facility was previously cited on 12/1/11.
|
Plan of Correction
Employee #14 has completed the facility's Department approved HIV/AIDS training. Employee #14 completed the training on December 6, 2012. The Human Resources Manager and or designee will conduct monthly audits of new hire and existing staff's educational/training plans located in the employee's personnel file to monitor adherence to State standards completion and timeframes. The results of the audit will be reported to the Executive Committee, internally called Human Resources Dashboard, for four months for oversight and monitoring. The Human Resources Manager will address any compliance issue directly with the employee in the form of counseling/coaching to bring the employee in compliance. |
705.10 (c) (3) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
|
Observations
Based on observation during a physical plant inspection, the facility failed to ensure that fire extinguishers were inspected and approved annually by the local fire department or fire extinguisher company.
The findings include:
A physical plant inspection was conducted on November 29, 2012, at approximately 10:00 AM.
The facility failed to ensure fire extinguishers were inspected and approved annually by the local fire department or fire extinguisher company.
It was observed that six out of ten fire extinguishers had not been inspected since September 2011.
The property manager confirmed the findings.
|
Plan of Correction
The facility's fire extinguisher company was on site November 29, 2012 conducting the fire extinguisher inspections. The facility had recently undergone a change in fire extinguisher companies due to unforeseen issues. The facility's Property Manager and or designee of the Engineering Department will continue weekly walk through physical plant/environment of care tours taking a proactive approach in facility and grounds risk management. The results of the audits will be reported on a monthly basis for the time frame of four months to the Executive Committees known as Safety Committee Dashboard. |
709.25(a) LICENSURE Fiscal Management
709.25. Fiscal management.
(a) The project shall obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services.
|
Observations
Based on a review of administrative documentation, the project failed to provide documentation of an independent annual audit of financial activities associated with the project's drug/alcohol abuse services.
The findings include:
The project's administrative records were reviewed for a financial audit on November 26, 2012. The project's fiscal year runs from July through June. The project failed to provide documentation of an independent annual audit for the July 2010 through June 2011 fiscal year.
The Project Director confirmed the findings.
This is a repeat citation. The facility was previously cited on 12/1/11.
|
Plan of Correction
An independent financial audit will be conducted of the Drug and Alcohol Program's financial activities for the periods of July 2010 to June 2011 fiscal year. An Independent CPA Firm has been engaged as of 5/23/2012. Full payment to initiate the audit has not been remitted due to the facility's current financial constraints in collecting outstanding payment due for services provided from one of the facility's major payors. The Chief Financial Officer will develop a financial plan and structure to collect the outstanding payments due. The financial plan will be reviewed with Senior Management staff on January 23, 2013 for approval of execution. The facility will designate the funds collected to payment of the CPA services for the conduction of the financial audit of the D&A programs for July 2010 through June 2011 fiscal year. This process and audit will be completed end of current fiscal year, June 30, 2013. The CFO will report the facility's financial status/results; progress of completion of the D&A's annual financial audit requirement,financial issues, AR/AP, stats, and other issues and opportunities to the Management Committee on a monthly basis for four months for monitoring and oversight. The Management Committee consists of the CEO, President, and senior leadership of the Kirkbride facility. The results of actions taken to resolve the financial constraints and progress towards that end will be reported by the CEO and the President to the Board of Directors. |
709.25(b) LICENSURE Fiscal Management
709.25. Fiscal management.
(b) Projects shall develop a service fee schedule which shall be posted in a prominent place.
|
Observations
Based on observation during a physical plant inspection, the facility failed to post the fee schedule in a prominent place.
The findings include:
A physical plant inspection was conducted on November 29, 2012, at approximately 10:00 AM.
The facility failed to post the fee schedule in a prominent place.
The facility did not dispute the findings.
|
Plan of Correction
The facility's fee schedule was located inside the Admission's Department on a bulletin board during survey available to be reviewed by incoming patients. At time of survey, the schedule was removed and placed on the door leading into the Admission's Department so that it is separate and apart from additional postings creating a greater opportuinity for the patient to review the fee schedule. The fee schedule will also be included in the Patient Handbook for review at any time by the patient. The Patient Handbook has been revised, it will go through approval phase of the Forms committee and available for print and distribution by February 1, 2013. The Clinical Director will has oversight of the Patient Handbook revision for the Drug and Alcohol Program. The Lead Social Worker for Inpatient Psychiatric Services will have oversight of the patient fee schedule inclusion in the Hospital Patient Handbook expected to be completed by February 1, 2013 |
709.63(a)(7) LICENSURE Discharge summary
709.63. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to the following:
(7) Discharge summary.
|
Observations
Based on a review of patient records, the facility failed to document a discharge summary describing the patient's reasons for treatment.
The findings include:
Four patient records requiring documentation of a discharge summary were reviewed on November 27, 2012. The facility failed to document a discharge summary describing the patient's reasons for treatment in four of four records reviewed, patient records # 5, 6, 7, and 8.
The facility did not dispute the findings.
This is a repeat citation. The facility was previously cited on 12/1/11.
|
Plan of Correction
The Clinical Director and Clinical Supervisor have designed a training for the Primary Therapists that encompasses the composite continuum picture of the client from admission to discharge and follow up that hones in on the stated and contributing factors to the patient's seeking of treatment and how the subjective and objective data should be documented in the discharge summary. The patient's challenges in his or her life; familial, social setting, economic and legal and community settings will be explored and how these factors identify the patient's reasons for treatment. Trainings will be conducted as a segment of the daily morning meetings.Once trainings are completed The Clinical Director and Clinical Supervisor will conduct an audit of 10% of closed charts for four months to determine compliance of the requirement for documentation of the reasons for treatment. Results of the audit will be reported monthly for four months to the Executive Committee, internally called Dashboard, for oversight and monitoring. Therapists determined to have need for further improvement will receive individualized support and additional trainings for a reasonable time frame by the Clinical Director and Supervisor. |
709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
|
Observations
Based on a review of patient records, the facility failed to document a psychosocial evaluation that included a composite picture of the patient, the patient's problems/needs, assets/strengths, support systems, coping mechanisms, negative factors, attitude toward treatment and/or the counselor's conclusions/impressions.
The findings include:
Sixteen patient records requiring documentation of a psychosocial evaluation were reviewed on November 28 - 29, 2012. The facility failed to document a psychosocial evaluation that included a composite picture of the patient, the patient's problems/needs, assets/strengths, support systems, coping mechanisms, negative factors, attitude toward treatment and/or the counselor's conclusions/impressions in seven out of sixteen records reviewed, Patient records # 15, 16, 17, 19, 21, 22, and 24.
Patient # 15 was admitted to the program on 7/2/12. The psychosocial evaluation was documented on 7/4/12. However, the facility failed document a psychosocial evaluation which included an assessment of the patient's assets/strengths, support systems, coping mechanisms, and negative factors and how they would impact treatment .
Patient # 16 was admitted to the program on 8/18/12. The psychosocial evaluation was documented on 8/22/12. However, the facility failed document a psychosocial evaluation which included an assessment of the patient's assets/strengths, support systems, coping mechanisms, negative factors and attitude toward treatment, and how they would impact treatment. Additionally, the psychosocial evaluation did not include the counselor's conclusions/impressions of the Patient.
Patient # 17 was admitted to the program on 5/5/12. The psychosocial evaluation was documented on 5/7/12. However, the facility failed document a psychosocial evaluation which included an assessment of the patient's assets/strengths, support systems, coping mechanisms and negative factors, and how they would impact treatment. Additionally, the psychosocial evaluation did not include the counselor's conclusions/impressions of the patient.
Patient # 19 was admitted to the program on 7/31/12. The psychosocial evaluation was documented on 8/1/12. However, the facility failed document a psychosocial evaluation which included an assessment of the patient's assets/strengths, coping mechanisms and the patient's attitude toward treatment, and how they would impact treatment.
Patient # 21 was admitted to the program on 7/18/12. The psychosocial evaluation was documented on 9/19/12. However, the facility failed to document a psychosocial evaluation which included an assessment of the patient's assets/strengths, support systems and coping mechanisms, and how they would impact treatment.
Patient # 22 was admitted to the program on 9/4/12. The psychosocial evaluation was documented on 9/5/12. However, the facility failed to document a psychosocial evaluation which included an assessment of the patient's problems/needs, assets/strengths, support systems, coping mechanisms and negative factors, and how they would impact treatment.
Patient # 24 was admitted to the program on 9/29/12. The psychosocial evaluation was documented on 9/30/12. However, the facility failed to document a psychosocial evaluation which included an assessment of the patient's assets/strengths, support systems, coping mechanisms and negative factors, and how they would impact treatment. Additionally, the psychosocial evaluation did not include the counselor's conclusions/impressions of the patient.
The facility did not dispute the findings.
This is a repeat citation. The facility was previously cited on 12/1/11.
|
Plan of Correction
The Clinical Director and The Clinical Supervisor have developed a series of trainings designed to assist the Therapist in the development of the composite picture of the client in the Psycosocial Assessment/Evaluation tool/documentation. These trainings are ongoing and are provided internally. They are geared toward helping the Therapist to explore with the client all aspects of their lives that brought them to chemical dependency and how these aspects influence their recovery and transformation. The PSA was revised post 2011 renewal survey to compartmentalize each section of the required components; composite picture of the patient, problems/needs, assets/strengths, support systems, coping mechanisms, negative factors, attitude towards treatment and/or the counselor's conclusions/impressions. For continued monitoring, the Clinical Director and the Clinical Supervisor will conduct an audit of 10% of closed charts with results reported on a monthly basis to the Executive Committee, internally known as Dashboard, for a period of four months. Therapists identified as having weaknesses in the required documentation will receive additional and individualized trainings conducted by the Clinical Director and or Clinical Supervisor. Counseling/coaching will occur with continued deficiency as identified. |
709.53(a)(10) LICENSURE Discharge Summary
709.53. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(10) Discharge summary.
|
Observations
Based on a review of patient records, the facility failed to document a discharge summary describing the patient's reasons for treatment six of ten records reviewed.
The findings include:
On November 28 - 29, 2012, ten patient records requiring documentation of a discharge summary were reviewed. The facility failed to document a discharge summary describing the patient's reasons for treatment in six of ten records reviewed, patient records # 15, 16, 17, 18, 19, and 20.
In addition, the facility failed to document the services offered on patient # 18's discharge summary.
The facility did not dispute the findings.
|
Plan of Correction
The Clinical Director and The Clinical Supervisor have developed trainings that focus on the development of the discharge summary to fully depict the client's continuum of care and the resources the client may access once back in the community. The trainings hone in on the required documentation that should be displayed in the patient's record to support the counseling and guidance afforded the patient during treatment.Presence of the completion of the components of the discharge summary will be audited by Medical Records on a monthly basis and submitted to the Clinical Director for review and follow up with the individual therapist if deficiency noted. The Clinical Director and the Clinical Supervisor will conduct a 10% audit of closed charts monthly to monitor compliance with the requirement for documentation of reasons for treatment, services offered, and qualitative value of the documentation. The audits will be conducted for a period of four months. the results will be reported to the Executive Committee, internally known as Dashboard. Continued therapist deficiencies will be addresed on an individual basis via counseling
/coaching. |
709.53(a)(11) LICENSURE Follow-up information
709.53. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(11) Follow-up information.
|
Observations
Based upon a review of patient records and the facility's policy and procedures manual, the facility failed to document follow-up information in accordance with facility policy.
The findings include:
The facility policy titled "follow-up" states:
Patients who do not receive continued services after discharge: The therapist will attempt to contact the patient via phone or mail within one week of discharge.
Two patient records requiring documentation of follow-up information were reviewed on November 27, 2012. The facility failed to document a follow-up within one week of discharge in two of two records reviewed, specifically client records # 12 and 13.
Patient # 12 was admitted to the program on 5/20/12 and discharged on 5/29/12. Per facility policy a follow-up was due by 6/5/12. There was no documentation of a follow-up in patient record # 12 as of the date of the inspection.
Patient # 13 was admitted to the program on 5/20/12 and discharged on 5/25/12. Per facility policy a follow-up was due by 6/1/12. There was no documentation of a follow-up in patient record # 13 as of the date of the inspection.
The Project Director confirmed the findings, as she stated that follow-up was not conducted on the patients.
|
Plan of Correction
A discharge follow up tool has been developed for the Acute Psychiatry program for dual diagnosed patients. The Acute Psychiatry Social Services staff have been inserviced on the facility's policy and procedure to conduct a followup within a week of discharge and document follow up report. The form is now in use and follow ups are conducted on all dual diagnosed patients. The Medical Records Department will conduct monthly audits of the completion of the followup tool and the timeframe of completion. The results will be given to the Project Director for review. Results will be monitored by the Project Director for a period of four months and reported monthly to the Executive Committee internally known as Dashboard. Deficiencies and or compliance concerns with this requirement will be reviewed by the Project Director directly with the Social Worker. Additional trainings and or counseling/coaching will be effected as needed. |
709.14(b)(5) LICENSURE Subchapter B.Licensing Procedures.Restriction
709.14. Restriction on license.
(b) The licensee, using Department forms, shall notify the Department within 90 days of the occurrence of any of the following conditions:
(5) Change in authorized maximum capacity.
|
Observations
Based on observation during a physical plant inspection and an interview with the Project Director, the facility failed to comply with the maximum approved capacity and failed to notify the Department within 90 days of a change in the authorized maximum capacity.
The findings include:
A physical plant inspection was conducted on November 29, 2012, at approximately 10:00 AM.
The facility is licensed by the Division for a maximum client capacity for 157 inpatient non-hospital drug-free beds.
The facility failed to ensure that 157 inpatient non-hospital drug-free beds were set-up and ready for use.
It was observed that 122 out of 157 inpatient non-hospital drug-free beds were set-up and ready for use.
The Project Director confirmed the findings. She stated during an interview that the main floor which is co-ed has 24 beds set up, the second floor which is designated for male patients has 30 beds set up, the third floor which is designated for male patients has 32 beds set up, and the fifth floor which is designated for female patients has 36 beds set up.
|
Plan of Correction
The C2 North floor which has the facility's additional 35 Rehab beds will be set up and ready for use by January 28, 2013 as reported by formal letter and via fax to the Business Analyst Department of Drug and Alcohol Programs, Division of Program Licensure on December 19, 2012. The Project Director will notify the Department within 90 days of any change in the authorized maximum capacity should any future needs arise that would require the facility to conduct repairs and or renovations necessitating a change in bed capacity. |